A Woman 40 Yo With Diabetic Mellitus Type

7/29/2019 A Woman 40 Yo With Diabetic Mellitus Type

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A WOMAN 40 YO WITH DIABETIC MELLITUS

TYPE 2 AND DIABETIC FOOT

D E L L A P U T R I A R I Y A N I

0 3 0 . 0 9 . 0 6 1

D O K T E R P E M B I M B I N G : D R . S U P R I S S P.

P D


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IDENTITY

Mrs. NardiahName

40 years oldAge

FemaleSex

Krajan KarawangAddress

High schoolEducation

-Occupation

MoeslemReligion

MarriedMarital status

June 20th 2012Admitted

SundaneseEthnic


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Main Complaint Additional Complaint

Pain in the right leg since

1 month agoNausea

dizziness


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HISTORY OF THE DISEASE

patients came to the hospital with complaints of pain

in the right foot. The perceived grievances 1 monthago.

Patient has a wound on the right leg since 3months ago. The injuries arise suddenly without

realizing patients, initial small wound extends long.

The wound was in surgery at one hospital.however, the wound is still oozing pus and smell.


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5 years ago patient cames to the clinic anddiagnosed with diabetes melitus. But she

didnt control regularly for her illness

3 month ago : patient has a wound on theright leg

2 month ago:The wound was in surgery atone hospital

1 months ago : the wound is still oozing pusand smell. And patien felt pain in her right foot.

June 20 2012, patient come to emergency unitof karawang hospital


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HISTORY OF THE PAST DISEASE

Diabetesmelitus (+)

Hipertension(-)

Asthma (-)

Allergy (-)

High uricacid (-)


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FAMILY HISTORY

Diabetesmelitus (+)her parent

Kidneydisease (-)

Allergy (-)Asthma (-)

Hypertension(-)

Heart disease(-)


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HABIT HISTORY

Alcohol consumption (-)

Smoking (-)

Routine exercise (-) Injected drugs (-)

Traditional beverages(-)

Coffe 1 cup/days

Patient are likely to eat sweet food

Patient are likely to eat a largeportion


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GENERAL CONDITION

Moderately illGeneralcondition

ComposMentis

Consciousness


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VITAL SIGN

VitalSigns

Blood Pressure

110/70 mmHg

RespirationRate

36X/minute

Pulse Rate

86x/minute,weak pulse

Temperature

38 C


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PHYSICAL EXAMINATIONHead

Normocephali

Eyes Anemic conjunctiva -/-,

Icteric sclera -/-

Mouth

Lip: cyanosis(-) dryness (-)

Pharynx: hyperemic (-), symmetrical, uvula at midline

Thypoid tounge -

Neck

Lymph gland & Thyroid gland is not palpable


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THORAX EXAMINATION

LungExamination

Inspection: Symmetrical

Palpation: Equal vocal fremitus

Percussion: Sonor

Auscultation: Vesicular breathsound in both lung, no ronchi andwheezing

HeartExamination

Inspection: Ictus cordis is available

Palpation: Ictus cordis is palpableat 5th ICS LMCS

Percussion :Right heart border: ICS III-V LSD

Left heart border: ICS V 1cm medial LMCS

Upper heart border: ICS III LPSS

Auscultation: Regular I - II heartsound no murmur and gallop


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ABDOMINAL EXAMINATION

Inspection:

Brown skin

Skinabnormality (-)

Palpation:

Sociable

Defensemuscular (-),mass (-)

Noenlargementof liver andspleen

Percussion:

No painpresent onabdominalpercussion

Sounds dull Shifting

dullness (-)

CVA (-)

Auscultation:

Bowel sound(+)

Arterial bruit (-)

Venous hum (-)


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EXTREMITY EXAMINATION

Warm acrals (+)Oedem (-)

Wound +/-

Range of Motion arelimited due to the pain

(numbness)


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LABORATORY EXAMINATIONJune 20,2013

RESULT Normal Range

Hemoglobin 9,2 (12 17) g%

Leucocytes 18.510 (5.000 10.000)/L

Thrombocytes 517.000 (150.000 450.000)/L

Ht 27 (37 43) %

Differential Count

Basophil 0 (0 1) %

Eosinophil 0 (1 3) %

Rod Neutrophil 0 (2 6) %

Segment Neutrophil

88

(50 70) %


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June 21, 2013

GDS : 357

RESULT Normal Range

Lymphocyte 8 (20 40) %

Monocyte 4 (2 8) %

Random Blood Glucose 311 (80 140) mg/dl

Ureum 51,5 (10 45) mg/dl

Creatinine 0,65 (0,4 1,5) mg/dl


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PHOTO RO


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RADIOLOGI OSTEOMIELITIS

7-10 days infectionsoft tissueswelling

10-14 days infection periostealreaction, sclerosis, involucrum

and scewstrum


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DIABETES MELITUS

Definition

A metabolic disorder of multiple etiology

characterized by chronic hyperglycemia with

disturbances of carbohydrate, fat and protein

metabolism resulting from defects in insulin

secretion, insulin action, or both.


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CHARACTERISTIC SYMPTOMS

1. Poliuria,

2. Polidipsi,

3. Polifagia,

4. Weight loss


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ATYPICAL SYMPTOMS

1. Fatigue and weakness

2. dizziness

3. Skin infections

4. Chronic itching

5. Poor healing of skin wounds6. Numbness of fingers and toes

7. Blurred vision

8. etc


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CRITERIA DIAGNOSA DM


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Hemoconcentration

trombosis

Aterosklerosi

s

Makrovaskul

er

Mikrovaskule

r


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Mikro

1.Diabeticcardiomyophaty

2.Diabeticnephrophaty

3.Diabeticneurophaty

4.Diabeticretinophaty

Makro

1.Coronary arterydisease

2.Diabeticmyonecrosis

3.Peripheralvascular disease

4.Stroke

COMPLICATION

Diabetic foot


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VASCULAR, INFECTION OR NEUROPHATY?


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EDMONDS 2004-2005

Stage 1: Normal Foot

Stage 2: High Risk Foot

Stage 3: Ulcerated Foot

Stage 4: Infected Foot

Stage 5: Necrotic Foot

Stage 6: Unsalvable Foot

Primary prevention

Care and

specialist

services

Hospitalization

and surgeon

Secondary

prevention


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MANAGEMENT OF DIABETIC FOOT

PRIMARY PREVENTIONbased on the magnitude of risk and the

risk of problems that may occur.

Classification based on the risk of diabetic foot

problems (Frykberg):a) Normal Sensation Without Deformityb) Normal sensation with deformities or HighPlantar Pressure

c) insensitivity Without Deformityd) Ischemia Without Deformitye) Combination / complicated


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SECONDARY PREVENTION

1. Metabolic control

2. Vascular control

3. Wound control

4. Microbiological control

5. Pressure control

6. Education control


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Metabolic:

control of blood sugar levels,

serum albumin level, hemoglobin

level and the degree of tissue

oxygenation and kidney function. All

of these factors will be poor healing

wounds if left unchecked and not

repaired.


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Vaskular

peripheral vascular abnormalities can

be identified simply as: color and

temperature of the skin, palpation of the

dorsalis pedis artery and posterior tibialarteries and added blood pressure

measurement. Management can be a risk

factor modification (atherosclerosis risk

factors and improve walking program),pharmacological therapy (improve patency

in vascular disease legs with DM) and

revascularisation (surgical therapy).


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Wound

adequate debridement and

topical therapy (saline for cleaning

wounds, or yodine watery liquid,

silver compounds as part of the

dressing).


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Microbacterial

antibiotics with a broad spectrum,

including Gram positive and negative

bacteria, combined with useful drugs

against anaerobic bacteria (such asmetronidazole).


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Pressure

if the fixed leg is used for walking,

which is always under pressure sores will

not have time to heal, if the wound is

located on the plantar as Charcot footulcers. To achieve non weight-bearing can

be done include: removable cast walker,

temporary shoes, wheelchair, total contact

casting.


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Education

With a good education, people with

diabetes or ulcer / gangrene diabetic and

his family are expected to be able to help

and support the actions necessary foroptimal wound healing.


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WORKING DIAGNOSIS

DM Type 2 with diabetic foot grade III


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THERAPY

Insulin Humalog (20-0-20)

Ceftriaxone 2x1

Metronidazole 3x500

Ketorolac 3x500

OMZ 2x1

PCT p.r.n


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PROGNOSIS

AdVitam:Bonam


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A Woman 40 Yo With Diabetic Mellitus Type

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